Stress, Anxiety, and Depression in the First-year Students of Medical Education: A Prospective Cohort Study from a Women’s Medical College in South India

Abstract

Background and Aims:

Medical students around the world have been found to have high rates of depression and anxiety as compared to the general population. This study aimed to assess these in medical students immediately after they joined medical school and six months later. This study also aimed to assess if there was any association with stress, anxiety, and depression scores at six months follow-up with coping styles, self-esteem, personality, family functioning, and academic performance.

Methods and Materials:

We enrolled 154 first-year undergraduate medical students in this study with a baseline assessment including sociodemographic factors and Depression, Anxiety, Stress Scale 21 (DASS 21). They were followed up at six months with assessments of DASS 21, family functioning using the Family Adaptability, Partnership, Growth, Affection, and Resolve Scale (APGAR), coping styles using the Brief Coping Orientation to Problems Experienced (Brief COPE) scale, personality factors using the Big Five Inventory (BFI-10) and self-esteem using Rosenberg Self-Esteem Inventory (RSES). Change in scores in DASS 21 was measured. The DASS 21 scores at six months were correlated with other scale scores using appropriate statistical tools. Logistic regression analysis was done to study the effect of different variables on the outcomes.

Results:

Mean DASS scores at baseline fell within the normal range. There was a significant increase in mean DASS scores six months after joining. Despite this, only three students reported receiving treatment for mental health problems. DASS scores showed positive correlations with neuroticism and emotion-focused coping styles. About 36.6% of students reported failing in at least one subject. Academic performance did not show any association with levels of psychological distress.

Conclusion:

Students showed a striking rise in psychological distress six months after joining medical school. This suggests that the medical school environment could play a role. To meet students’ needs, a change in medical school culture and the provision of accessible and flexible mental health services are required.

Key Message:

Undergraduate medical students, in the first year, face a significant risk of psychological distress over the initial part of their course. It is imperative to look for mental health issues and establish means of easy access to mental health services for students with needs.

India has over 600 medical schools with a total capacity of over 90,000 students. Governmental reforms are ongoing to increase the number of medical schools and address the dismal doctor-patient ratio in many parts of the country. Medical students around the world have been found to have high rates of depression and anxiety as compared to the general population. ¹ A meta-analysis of Indian studies measuring depression in medical students found pooled prevalence of 40%. ² This has been associated with reduced productivity, burnout, and decreased empathy toward patients, potentially affecting the kind of doctor they become. Some studies have shown reduced academic performance in students with more psychological distress.^3,4

A few longitudinal studies have suggested that levels of depression and anxiety increase as a student progresses through medical school.^5,6 This suggests that the environment of medical school might play a role. Much has been written about the “hidden curriculum” of medical school, a cultural process whereby certain values, judgments, and behaviors are taught to the students. ⁷ Medical school has a demanding curriculum incorporating both theory and practical skills obtained through clinical rotations. In addition, students face the challenge of preparing for highly competitive entrance exams to obtain admission into postgraduate training.

Students must bear the burden of their parent’s expectations and face intense pressure to succeed in what is often a hostile environment. Their coping styles, social support system, and personality would all play a role in determining the level of resilience they have. ⁸ In this context, it is essential to understand the psychological well-being and needs of medical students to design appropriate mental health interventions. So far, studies have used cross-sectional design and have focused on looking at depression, anxiety, stress, and its association with coping skills. In our study, we aimed to further the understanding regarding the role of personality factors, self-esteem, and family functioning in relation to psychiatric morbidity. We used a prospective cohort design to also understand the change in mental health during the first academic year of the students.

Methodology

Setting and Participants

This prospective cohort study was conducted in a tertiary care hospital and medical college in southern India. This study participants were newly joined Bachelor of Medicine and Bachelor of Surgery (MBBS) students. Since all first-year students were included in this study, formal sample size and power calculation still needed to be done. The Institutional Ethics Committee approved this study. Online informed consent was obtained from the students. Students who did not consent were excluded from this study.

Procedure

Data was collected using an online questionnaire created on Google Forms. Students were assessed at baseline (T1) from January 2023 to February 2023, within the first week of joining medical school, and at six months (T2) after joining, from July 2023 to August 2023. A period of six months was considered to give enough time to adjust to the new environment and to avoid any confounding effects of the first-year exams. Data on sociodemographic and clinical profiles was collected at baseline. Student names and roll numbers were also collected to link T1 and T2 data.

Given that the data was not anonymous, it was handled in password-protected computers and only by investigators, thereby protecting confidentiality. Psychological distress was measured using the Depression, Anxiety, and Stress Scale (DASS 21) at baseline (T1) and after six months (T2). In addition, at six months (T2), family functioning was assessed using the Family Adaptability, Partnership, Growth, Affection, and Resolve Scale (APGAR) scale, which measures adaptability, partnership, growth, affection, and resolve. Coping styles were assessed using the Brief Coping Orientation to Problems Experienced (Brief COPE) scale, personality factors using the Big Five Inventory (BFI), and self-esteem using the Rosenberg Self-Esteem Inventory (RSES). These were done only once as they are relatively stable over time and to avoid fatigue in participation. Information on academic performance was collected from the students at six months. To address the risk of bias due to loss of follow-up, participants with incomplete data were excluded from the analysis. Since the tools were self-rated, the risk of interviewer bias was minimal. All participants were provided with contact details of the primary investigator to freely seek help for any mental health condition that may emerge during this study. Those who sought help were given free treatment.

Instruments

The DASS 21 comprises three self‑reported scales that measure symptoms of anxiety, depression, and stress. It has been shown to have good internal consistency and convergent and discriminant validity. ⁹ The BFI-10 is a shorter 10-item version of the 44-item Big Five Personality Inventory with good reliability and validity. The items measure the core aspects of the Big Five factors of openness to experience, agreeableness, neuroticism, extraversion, and conscientiousness. ¹⁰ The Brief COPE is a reliable and commonly used scale to assess an individual’s coping strategies. Coping can be defined as the thoughts and behaviors mobilized to manage the demands of stressful situations. The items fall into three domains: problem‑focused coping (PC), emotion‑focused (EC) coping, and avoidance coping (AC). ¹¹

The Family APGAR scale assesses the individual’s view of the state of functioning of his family. The acronym APGAR is derived from its items relating to domains of adaptation, partnership, growth, affection, and resolve. It has good psychometric properties. ¹² Rosenberg’s Self-Esteem Scale is a widely used measure of self-esteem. It comprises ten items, five of which are negatively worded. It has good internal and temporal consistency. ¹³ These scales have been used by students in India, including those in medical colleges.^14–16

Data Analysis

Duplicate entries were identified and removed using participants’ phone numbers. Statistical analysis was performed with licensed Statistical Package for Social Sciences (SPSS) software, version 26.0. ¹⁷ The data was checked for normality using the Shapiro–Wilk test. Descriptive statistics were used to analyze the sociodemographic and clinical variables. Measures of central tendency were used for the quantitative variables, and frequencies with percentages were calculated for the qualitative variables. Wilcoxon signed-rank test was used to assess the change in DASS scores with time. The relationship between the DASS 21 score at T2 and the other variables collected at T2 was assessed using the Spearman correlation test. Mann–Whitney U test was used to analyze the association between academic performance and this study measures at T2. A bivariate logistic regression was used to measure the association between independent variables (DASS subscale scores) and dependent variables. For the bivariate regression analysis, DASS 21 scores were grouped into “Normal” versus “Mild/Moderate/Severe” as described by the severity rating. Missing value imputation was not done, and cases with missing values were eliminated from the analysis. P value < .05 was considered significant.

Results

Out of a batch of 175 students, 154 and 134 students completed the questionnaire at T1 and T2, respectively. The reason for the dropout of participants could not be elicited and could be attributed to the expected attrition rate in follow-up studies. The sociodemographic and clinical characteristics of the respondents are presented in Table 1. The mean age was 19 years. The majority belonged to the state of Andhra Pradesh and stayed in university accommodation. Most students came from nuclear families and belonged to middle or upper socioeconomic class. The majority did not have a past or family history of psychiatric illness. Substance use was minimal at both time points. Only three students were on treatment for mental health-related problems at T2.

Table 1.

Characteristics of Respondents.

Characteristics of Respondents (N = 154)		Mean (SD) or Frequency (%)
Age		19.13 (1.13)
Residents of other states		4 (29.2)
Residence	Rural	49 (31.8)
	Semi-urban	28 (18.2)
	Urban	65 (42.2)
	Metropolitan	12 (7.8)
Family type	Joint	13 (8.4)
	Nuclear	141 (91.6)
Income category	>120,000	26 (16.9)
	60,000–120,000	49 (31.8)
	46,000–60,000	20 (13.0)
	30,000–46,000	9 (5.8)
	18,000–30,000	16 (10.4)
	6000–18,000	34 (22.1)
History of psychiatric illness	No	151 (98.1)
	Yes	3 (1.9)
History of psychiatric treatment	No	149 (96.8)
	Yes	5 (3.2)

SD, standard deviation.

Table 2 displays the DASS scores at both time points. At T1, students had mean DASS scores of 5.58, 5.13, and 4.18 on anxiety, stress, and depression subscales, respectively, which fall within the normal range. Wilcoxon signed-rank test was used to analyze the change in scores and was found to be significant. At T2, the mean scores increased to 10.22, 12.18, and 8.82 in anxiety, stress, and depression subscales, respectively. There was an increase in the proportion of students who fell within the moderate-to-severe range in DASS scores at T2, as shown in Table 3.

Table 2.

Anxiety, Stress, and Depression: Differences Between the Two-time Points.

Scale	T1 (N = 154) Mean (SD)	T2 (N = 134) Mean (SD)	Wilcoxon sign rank test value	Z	P Value
DASS anxiety subscale score	5.58 (3.452)	10.22 (7.405)	6519.00	5.91	<.001
DASS stress subscale score	5.13 (3.460)	12.18 (7.601)	78292.50	8.30	<.001
DASS depression subscale score	4.18 (4.380)	8.58 (8.167)	6200.50	5.80	<.001

Table 3.

Anxiety, Stress, and Depression: Categorized According to Severity.

Scale		T1 (N = 154) Mean (SD)	T2 (N = 134) Mean (SD)
DASS-A	Normal	101 (65.58)	49 (36.57)
	Mild	32 (20.78)	16 (11.94)
	Moderate	18 (11.69)	41 (30.60)
	Severe	3 (1.95)	12 (8.96)
	Extremely severe	0	16 (11.94)
DASS-S	Normal	142 (92.21)	63 (47.02)
	Mild	11 (7.14)	49 (36.57)
	Moderate	1 (0.65)	16 (11.94)
	Severe	0	5 (3.73)
	Extremely severe	0	1 (0.75)
DASS-D	Normal	136 (88.31)	86 (64.18)
	Mild	7 (4.54)	21 (15.67)
	Moderate	11 (7.14)	13 (9.70)
	Severe	0	9 (6.72)
	Extremely severe	0	5 (3.71)

DASS-A: Anxiety subscale of DASS 21, DASS-S: Stress subscale of DASS 21, DASS-D: Depression subscale of DASS 21.

Table 4 shows the scores obtained in the various study instruments. The students had a mean score of 21.4 on the Rosenberg Self-Esteem Scale, which falls within the normal range. Students were more likely to use problem and emotion-focused coping than avoidant coping, although there was a wide variation in responses. In the BFI, students had a higher score in agreeableness than in other domains. The mean APGAR scores fell within the range for highly functional families.

Table 4.

Self-esteem, Coping, Personality Traits, and Academic Performance.

Scale (T2)	Mean (SD)
Rosenberg’s self-esteem scale score	21.4 (3.82)
Brief COPE coping styles
Problem-focused	20.22 (5.03)
Emotion-focused	25.57 (5.18)
Avoidant	14.04 (3.22)
Big Five personality traits
Extraversion	6.02 (1.92)
Agreeableness	8.01 (1.50)
Conscientiousness	6.07 (1.84)
Neuroticism	5.81 (1.9)
Openness to experience	6.92 (1.60)
Family APGAR	8.58 (1.92)
Academic performance
Failure in exam	49 (36.6)
No failure in the exam	85 (63.4)
Decline in performance	38 (28.4)
No decline in performance	96 (71.6)

The correlation between DASS 21 at T2, Brief COPE, APGAR, RSS, and BFI scales was analyzed using Spearman’s rank correlation as shown in Table 5. The three DASS subscales showed a moderate positive correlation with each other. DASS subscale scores across time have been shown in Figure 1. The DASS depression scale showed a moderate positive correlation with RSS, while the DASS anxiety and stress subscales showed a weak positive correlation. DASS and RSS showed a weak negative correlation with family functioning as measured by APGAR. DASS subscales showed a weak negative correlation with the trait of extroversion and a weak positive correlation with the trait of neuroticism. DASS depression and anxiety subscales showed weak positive correlations with emotion-focused and avoidant coping.

Table 5.

Correlations Between DASS 21 Subscales, Rosenberg’s Self-esteem Scale, Family APGAR, Brief COPE Coping Styles, and Big Five Personality Traits.

Scale	1. DASS_D	2. DASS_S	3. DASS_A	4. RSES	5. APGAR	6. COPE-PF	7. COPE-EF	8. COPE-A	9. BFI-E	10. BFI-A	11. BFI-C	12. BFI-N	13. BFI-O
1. DASS_D
2. DASS_S	0.58**
3. DASS_A	0.51**	0.63**
4. RSES	0.55**	0.27**	0.30**
5. APGAR	–0.34**	–0.25**	–0.23**	–0.45**
6. COPE-PF	0.02	0.09	0.13	–0.32**	0.14
7. COPE-EF	0.21*	0.04	0.22*	–0.01	–0.01	0.64**
8. COPE-A	0.28**	0.15	0.26**	0.16	–0.126	0.42**	0.55**
9. BFI-E	–0.23**	–0.29**	–0.23**	–0.13	0.06	–0.03	–0.11	–0.10
10. BFI-A	–0.10	0.08	0.08	–0.20*	0.30**	0.06	–0.02	–0.02	–0.03
11. BFI-C	–0.18*	–0.14	–0.15	–0.19*	0.14	0.20*	0.04	–0.02	0.06	0.09
12. BFI-N	0.36**	0.45**	0.32**	0.26**	–0.21*	–0.01	0.06	0.05	–0.31**	–0.07	–0.19*
13. BFI-O	–0.02	0.08	0.02	–0.14	–0.06	0.13	0.03	–47.32	–0.02	–0.10	0.01	–0.06

DASS-D: Depression subscale score, DASS-S: Stress subscale score, DASS-A: Anxiety subscale score, RSES: Rosenberg self-esteem scale score, APGAR: Family APGAR Index, COPE-PF: Problem-focused coping, COPE-EF: Emotion-focused coping, COPE-A: Avoidance coping, BFI-E: Extraversion, BFI-A: Agreeableness, BFI-C: Conscientiousness, BFI-N: Neuroticism, BFI-O: Openness to experience.

Figure 1. Change in Mean DASS 21 Scores from T1 to T2.

After six months, 36.6% reported failing in at least one subject, and 71.6% reported a decline in their academic performance, as shown in Table 4. Academic performance was not associated with any sociodemographic or clinical characteristics of the students, and it was not associated with scores on the DASS or any of the other scales.

A multivariate stepwise backward logistic regression analysis was used to examine the association between stress, anxiety, depression (dependent variables), and the sociodemographic variables, clinical, academic, personality traits, coping, family functioning, and self-esteem (independent variables) (Table 6).

Table 6.

Logistic Regression Analysis.

	Adjusted odds ratio [95% CI]	P Value	Nagelkerke r2
Stress
Agreeableness	1.50 [1.07–2.12]	.02	0.35
Neuroticism	1.47 [1.13–1.92]	.00
Self-esteem	1.33 [1.14–1.55]	.00
Problem-focused coping style	1.12 [1.01–1.24]	.04
Anxiety
Extraversion	0.72 [0.58–0.89]	.00	0.20
Agreeableness	1.40 [1.05–1.88]	.02
Family functioning	0.69 [0.52–0.91]	.01
Depression
Avoidance	1.15 [0.99–1.32]	.05	0.39
Self-esteem	1.40 [1.22–1.61]	.00
Family history of psychiatric illness	4.80 [1.16–19.89]	.03

The model for depression included avoidant coping style, total self-esteem score, and family history of psychiatric illness. These variables accounted for approximately 39% of the variance in the depression scores. The adjusted odds of scoring high on depression were almost five times higher in students with a family history of psychiatric illness as compared to the rest (adjusted odds ratio [aOR] = 4.80, 95% confidence interval [CI] = 1.16–19.89).

The model for anxiety included personality traits of extraversion, agreeableness, and family functioning, which accounted for approximately 21% variance in the anxiety scores. Both family functioning (aOR = 0.69, 95% CI = 0.52–0.91) and personality traits of extraversion (aOR = 0.72, 95% CI = 0.58–0.89) were found to be protective for anxiety. The personality trait of agreeableness was found to have a higher risk of developing anxiety (aOR = 1.40, 95% CI = 1.05–1.88).

A similar analysis for stress identified four variables as significant, that is, personality traits of agreeableness (aOR = 1.50, 95% CI = 1.07–2.11) and neuroticism (aOR = 1.47, 95% CI = 1.13–1.92), problem-focused coping style (aOR = 1.12, 95% CI = 1.01–1.24) and total self-esteem score (aOR = 1.33, 95% CI = 1.14–1.55). All these variables were risk factors for stress, and the model explained about 35% of the variance in stress.

Discussion

This study showed a striking rise in psychological distress in medical students a mere six months after starting medical school. At baseline, the majority of students scored within the normal range in DASS. Previous studies have shown similar results with normal levels of psychological distress at baseline and increase after joining medical school.^5,6 The rise in symptoms during MBBS would suggest that environmental factors are at play. The medical school involves intense competition and a demanding curriculum. Students often prepare for postgraduate entrance exams in addition to their coursework. This occurs in the background of a rigid hierarchy where juniors must defer to their seniors and obey them. However, a systematic review found that rates of depression are highest one year after joining, followed by a gradual decrease. ¹⁸ It is possible that the first year of medical school is especially stressful, being a time of transition and adjustment to a new environment. Longer studies would be required to delineate the course of psychological distress.

DASS scores showed a mild negative correlation with family functioning as measured by APGAR. There was also a mild positive correlation between DASS scores and neuroticism and a mild negative correlation between DASS scores and extraversion. This is keeping in line with the existing research where depression has been found to be consistently associated with higher neuroticism and lower extraversion. ¹⁹ The students mostly scored within the normal range in RSES and APGAR. Women consistently show more agreeableness, which is reflected in the higher score obtained in BFI for agreeableness in our study. ²⁰ DASS scores were positively correlated with RSS scores. Considering that depression is commonly associated with low self-esteem, such a correlation is unexpected and likely spurious. ²¹

Only three students were undergoing some form of treatment for mental health-related problems, which is low. A systematic review found that only 12.9% of students with depression had sought treatment. ¹⁸ Various reasons for this have been reported, such as the stigma of mental illness and the need to be perceived as competent doctors. ²² Indian studies have identified a preference for informal consultations, poor awareness about available services, and stigma to be barriers to seeking treatment.^23,24 No association was found between scores on DASS and other study instruments with academic performance.

The strengths of this study are the use of multiple instruments and assessments at two time points. Limitations of this study include limited generalizability, as this study population consisted of female students from a single state. This was an online survey that had multiple duplicate entries, so responder bias could not be ruled out. Data on academic performance was self-reported, which reduced its reliability. Multiple studies have found increased levels of bullying and harassment among healthcare professionals. ²⁵ In India, caste-based discrimination has been a significant cause of distress in students, recently highlighted by the unfortunate suicides of doctors due to caste-related bullying. ²⁶ This study did not collect data regarding participants’ caste and ethnicity.

Despite these limitations, this study demonstrates that early intervention might be necessary, considering the rise in psychological distress soon after joining medical school. Further studies, including those with qualitative or mixed methods, would be required to identify the difficulties faced by medical students. It is imperative that medical colleges invest in accessible student wellness services and destigmatization of mental health difficulties. Services need to be welcoming and flexible, and administrative assistance must be provided to students when required. It is imperative that services are respectful of the student’s need for confidentiality and avoid penalizing them for their mental health problems. This might require a change in the culture and attitudes of medical school, where having mental health problems is often perceived as incompetency. This study makes a case for the development of student health services and student wellness centers in medical colleges.